Corrections GI 3 Flashcards
What 2 investigations are contraindicated in ulcerative colitis in the acute setting?
1) colonscopy
2) barium enema
due to risk of bowel perforation
What barium enema findings would you expect to see in ulcerative colitis?
- lead-piping inflammation (2ary to loss of haustral markings)
- thumb-printing (a marker of bowel wall inflammation)
- pseudopolyps (due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa)
Cause of pseudopolyps in UC?
Due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa.
Cause of lead-pipe appearance on barium enema in UC?
2ary to loss of haustral markings
What is the first line medical treatment to maintain remission in Crohns?
Azathioprine or mercaptopurine
What neurological complications can be seen in coeliac disease? (3)
1) Loss of balance: ataxia, loss of coordination, falls
2) Sensory symptoms: numbness in glove and stocking distribution
3) Headaches
Cause of loss of balance in coeliac?
Gluten ataxia
Cause of sensory symptoms in coeliac?
Gluten neuropathy
Cause of headaches in coeliac?
Gluten encephalopathy
Management of gastroparesis (3)?
1) Diet e.g. low fibre, smaller/more frequent meals
2) 1st line: domperidone (dopamine receptor antagonist)
3) 2nd line: metoclopramide or erythromycin (motility agents)
What are the management options in a peri-anal abscess?
IV Abx, examination under anaesthetic with incision and drainage
What are the extra-intestinal signs of Crohn’s disease?
1) Erythema nodosum
2) Arthritis
3) Gallstones
4) Renal stones
5) Ocular: anterior uveitis & episcleritis
Which type of inflammatory bowel disease are non-caseating granulomas seen in?
Crohn’s
What is the initial medical management of a severe flare of ulcerative colitis?
Admit to hospital for IV steroids and rehydration
What is the cause of Gilbert syndrome?
Reduced activity of UDP glucuronosyltransferase (the hepatic enzyme responsible for conjugation of bilirubin) resulting in indirect hyperbilirubinemia.
Which alternative serological test can be performed if IgA anti-TTG is weakly positive in coeliac disease?
Anti EMA
hat is the inheritance pattern of haemochromatosis? (1)
What gene is affected? (1)
Autosomal recessive
Human haemachromatosis protein (HFE) gene
What medication is used for diarrhoea symptoms in irritable bowel syndrome? (1)
Loperamide
What is the usual screening test for Helicobacter pylori infection in the community? (1)
Stool antigen test
What medications are used to manage hepatic encephalopathy? (2)
1) Lactulose (aiming for 2-3 soft stools daily)
2) Abx, usually rifaximin
What scoring system is used to assess the severity of liver cirrhosis and the prognosis? (1)
Child Pugh score
What are the top genetic diseases that cause liver cirrhosis? (3)
Haemachromatosis
Wilson’s
A1AT deficiency
What is the inheritance pattern of alpha-1 antitrypsin deficiency? (1)
What gene is affected? (1)
Autosomal co-dominant
SERPINA1 gene coding for alpha-1 antitrypsin on chromosome 14
Which hepatitis B marker is used to screen for active infection? (1)
Surface antigen HBsAg
What specific enzyme is central to how alpha-1 antitrypsin deficiency affects the lungs? (1)
Neutrophil elastase
What investigation is used to assess the stiffness of the liver using high-frequency sound waves to determine the degree of fibrosis and cirrhosis? (1)
Transient elastography (“Fibroscan”)
What are the options for prophylaxis of bleeding in stable oesophageal varices? (2)
1) Propanolol
2) Variceal band ligation
What test for Helicobacter pylori can be performed during an endoscopy procedure? (1)
Rapid urease test (CLO test)
What treatment may be used to induce remission in Crohn’s disease where there are concerns about the side effects of drugs, particularly in children? (1)
Enteral feeding
What tool is used in alcohol withdrawal to score a patient on their symptoms and guide treatment? (1)
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) tool
What treatment for liver cancer involves injecting chemotherapy directly into the hepatic artery that feeds the tumour? (1)
Transarterial chemoembolisation (TACE)
What are the four most common causes of liver cirrhosis? (4)
1) Alcohol related liver disease
3) Non-alcoholic fatty liver (NAFLD)
3) Hep B
4) Hep C
Which type of viral hepatitis is a DNA virus, as opposed to the other types, which are RNA viruses? (1)
Hep B
What investigation is used to confirm the diagnosis of inflammatory bowel disease? (1)
Colonoscopy with multiple intestinal biopsies
What features indicate decompensated liver disease (as opposed to compensated)? (4)
1) Ascites
2) Bleeding oesophageal varices
3) Jaundice
4) Hepatic encephalopathy
What treatment causes vasoconstriction and slows bleeding in patients with bleeding oesophageal varices? (1)
What other medical treatment is routinely given with bleeding varices and why? (2)
Terlipressin
Prophylactic Abx: shown to reduce mortality
What is the first-line treatment for maintaining remission in ulcerative colitis? (1)
Topical +/- oral 5-ASAs e.g. mesalazine
What condition causes a drop in haemoglobin and a rise in bilirubin? (1)
Why does bilirubin rise in this situation? (1)
Haemolytic anaemia
Bilirubin released with RBCs rupture
What blood test is the first-line investigation for assessing fibrosis in non-alcoholic fatty liver disease? (1)
Enhanced liver fibrosis (ELF)
What key risk factors for peptic ulcers involve disruption of the mucus barrier? (2)
H. pylori infection
NSAIDs
What is the tumour marker for cholangiocarcinoma? (1)
Ca19-9
What liver enzyme is particularly raised in primary sclerosing cholangitis? (1)
ALP
What two skin signs may be seen on examination of a patient with primary biliary cholangitis, and what is the underlying cause of these changes? (2)
1) Xanthelasma (cholesterol deposists in skin) –> caused by high serum cholesterol
2) Jaundice –> caused by high serum bilirubin
Which two types of receptor does alcohol act on in the brain, and what effect does it have on those receptors? (2)
1) Stimulates GABA
2) Inhibits glutamate receptors (NMDA receptors)_
What time period after stopping drinking does delirium tremens start? (1)
24-72 hours
What effect does alcohol have on the mean corpuscular volume (MCV)? (1)
Raised
What scoring system is used after endoscopy to estimate the risk of rebleeding and mortality in upper GI bleeding? (1)
Rockall
Patients with which condition are screened every six months for liver cancer? (1)
What does screening involve? (2)
Liver cirrhosis
Liver US & alpha fetoprotein
What type of organism is Helicobacter pylori? (3)
Gram negative aerobic
What interventional radiology procedure may be used as secondary prevention of bleeding oesophageal varices? (1)
What is the other major indication for this procedure? (1)
Transjugular portosystemic shunt (TIPS)
Refractory ascites
What stool test is used to screen for inflammatory bowel disease? (1)
Faecal calprotectin
What blood test is considered in women (but not men) when excluding other causes of the symptoms of irritable bowel syndrome? (1)
What does this screen for? (1)
Ca125
Ovarian cancer
What surgical procedure may be used to treat ulcerative colitis definitively? (1)
Panproctocolectomy (removing the entire large bowel and rectum)
What is an alternative for maintaining remission in Crohn’s where 1st line options are not suitable?
Methotrexate
Is episcleritis more common in Crohn’s or UC?
Crohn’s
Is uveitis more common in Crohn’s or UC?
UC
Where is abdo pain typically prevalent in UC?
LLQ
1st line medications in IBS?
a) for constipation
b) for diarrhoea
c) for cramps
a) bulk forming laxatives e.g. ispaghula husk
b) loperamide
c) antispasmodics e.g. mebeverine, hyosine butylbromide
What laxative is AVOIDED in IBS?
Lactulose (can cause bloating)
What is mebeverine?
An antispasmodic used in the symptomatic treatment of stomach pain and spasms associated with IBS.
Other treatment options in IBS where symptoms remain uncontrolled? (3)
1) Low dose TCAs
2) SSRIs
3) CBT
Coeliac disease is associated with what 2 human leukocyte antigen (HLA) genotypes?
1) HLA-DQ2 (95%)
2) HLA-DQ8 (80%)
Rarely coeliac disease can present with neurological symptoms.
What are some of these symptoms? (3)
1) Sensory disturbance (peripheral neuropathy)
2) Ataxia
3) Epilepsy
How can coeliac lead to anaemia?
Anaemia occurs secondary to malabsorption and deficiency of iron, B12 or folate.
What is a key dermatological manifestation of coeliac?
Dermatitis herpetiformis
How to test for coeliac in patients with IgA deficiency?
Test the IgG version of anti-TTG or anti-EMA
Next investigations in patients with a positive Ab test in coeliac?
Confirmed via endoscopy and jejunal biopsy.
Gold standard for coeliac diagnosis?
Endoscopy intestinal biopsy
2 key biopsy findings that support coeliac disease?
1) Villous atrophy
2) Crypt hyperplasia
How can coeliac disease cause hyposplenism?
Thought to be due to excessive loss of lymphocytes through the inflamed enteric mucosa.
Is folate deficiency or vitamin B12 deficiency more common in coeliac?
Folate
During the first stages of treatment, goserelin may cause a transient increase in symptoms of prostatic cancer.
What can be given alongisde?
Anti-androgen e.g. flumatide
1st line management of patients with symptomatic perianal fistulae?
Oral metronidazole
Management of a perianal abscess?
Incision + drainage + Abx therapy
What drugs should be avoided in hepatic encephalopathy?
1) benzos
2) opiates
3) antidepressants
4) antipsychotics
Which IBD is ‘cobblestone mucosa’ seen in?
Crohn’s - due to ulceration and mural oedema
What should be checked before starting Azathioprine or Mercaptopurine?
Why
Assess for thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine.
The enzyme TPMT provides a major catabolic pathway for these drugs. In the absence of TPMT activity there will be an over-dose effect, resulting in complete bone marrow supression.
What does a transjugular intrahepatic portosystemic shunt procedure (TIPS) connect?
The hepatic vein and the portal vein
How long before an upper GI endoscopy should PPIs be stopped?
2 weeks
What is the recommended treatment option for patients with Barrett’s oesophagus and high grade dysplasia?
Endoscopic mucosal therapy e.g. radiofrequency ablation (RFA) or endoscopic resection (ER).
This is ecause high-grade dysplasia is considered a precursor to oesophageal adenocarcinoma.
Which cancer are patients with coeliac more at risk of developing?
enteropathy-associated T-cell lymphoma of small intestine
Which medications should be withheld in a C. diff infection?
Medications which are anti-motility and anti-peristaltic e.g. opioids.
If possible, antibiotics should also be held to allow normal intestine flora to be re-established, though the antibiotics used to treat the Clostridium difficile should be continued.
Why should opioids be discontinued in C. diff infection?
Can predispose to toxic megacolon
What is the treatment of chioce for small bowel bacterial overgrowth syndrome?
Rifaximin
Why is rifaximin good for small bowel bacterial overgrowth syndrome?
Rifaximin is poorly absorbed via the GI therefore allowing a large dose of antibiotic to reach its intra-luminal target without systemically high concentrations.
1st line Abx for perianal fistula in Crohn’s?
Oral metronidazole
What are some early signs of haemachromatosis?
Fatigue, ED and arthralgia
What medication is indicated in ongoing diarrhoea in Crohn’s patient post-resection with normal CRP?
Cholestyramine
Diarrhoea is most likely due to bile acid malabsorption as a complication of the resection.
What is cholestyramine?
A bile acid sequestrant with the potential to control diarrhoea induced by bile acid malabsorption.
How are liver abscesses generally managed?
With a combination of Abx & drainage
What are the grades of hepatic encephalopathy?
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
What is the investigation of choice in PSC?
ERCP/MRCP
Before starting ursodeoxycholic acid for primary biliary cholangitis, what investigation is required?
MRCP to exclude extrahepatic biliary obstruction, such as that caused by malignancies, before confirming the diagnosis.
How can a diagnosis of small bowel bacterial overgrowth syndrome be made?
Hydrogen breath test
What investigation may be useful for diagnosing and monitoring the severity of liver cirrhosis?
Transient elastography
Management of all patients with a suspected upper GI bleed?
Endoscopy within 24 hours
Which antibiotic is most closely associated with the development of C. difficile?
Clindamycin
What sign can be seen on barium swallow in patients with oesophageal cancer?
‘Apple core sign’ - anatomical narrowing of oesophagus.
Which area is most likely area to be affected by ischaemic colitis?
Splenic flexure - ‘watershed area’
What does a positive HBsAg result imply?
Acute or chronic hepatitis B
What does a positive anti-HBs result imply?
Immunity either through previous immunisation or disease.
What is the investigation of choice in a suspected pharyngeal pouch?
Barium swallow combined with dynamic video fluoroscopy
What condition associated with inflammatory bowel disease involves rapidly enlarging, painful skin ulcers, often on the legs? (1)
Pyoderma gangrenosum
What proportion of newly infected patients with hepatitis C will develop chronic hepatitis C? (1)
75%
What marker on a blood test is often the first indication of non-alcoholic fatty liver disease? (1)
Raised ALT
What procedure can be used to treat dominant strictures in primary sclerosing cholangitis? (1)
ERCP
What scoring systems are available to estimate the degree of liver fibrosis in patients with non-alcoholic fatty liver disease? (2)
1) NAFD Fibrosis Score (NFS)
2) Fibrosis 4 (FIB-4) score
What scoring system gives an estimated 3-month mortality as a percentage for patients with liver cirrhosis? (1)
MELD (model for end stage liver disease) score
What is the diagnostic imaging investigation for primary sclerosing cholangitis? (1)
MRCP
What is the pathophysiology behind how certain genotypes of alpha-1 antitrypsin deficiency affect the liver? (1)
The liver produces an abnormal mutant version of the A1AT protein, which builds up in the liver cells and has a toxic effect, causing inflammation.
Which type of viral hepatitis is only found in patients that also have hepatitis B? (1)
Hep D
How is hepatitis A transmitted? (1)
Faeco-oral route
What are the top autoimmune causes of liver cirrhosis? (3)
1) Autoimmune hepatitis
2) PSC
3) PBC
What organisms most commonly cause spontaneous bacterial peritonitis? (2)
1) E. coli
2) Klebsiella pneumoniae
What antibodies are most specific to primary biliary cholangitis and form part of the diagnostic criteria? (1)
AMA
Which type of viral hepatitis can be cured with direct-acting antivirals? (1)
Hep C
What 2 copper chelating agents are used in Wilson’s?
1) penicillamine
2) trientine
What large vessels drain into the portal vein before it enters the liver? (2)
1) Superior mesenteric vein
2) Splenic vein
What are the three stages of progression in alcohol-related liver disease? (3)
1) Alcoholic fatty liver
2) Alcoholic hepatitis
3) Cirrhosis
What surgical option is available for severe gastro-oesophageal reflux disease? (1)
Laparoscopic fundoplication
What is the main medical treatment for primary biliary cholangitis? (1)
Ursodeoxycholic acid
What gene is implicated in haemochromatosis?
HFE gene
What is the normal function of alpha-1 antitrypsin? (1)
Protease inhibitor
What regular monitoring for complications is carried out in patients with liver cirrhosis? (3)
1) MELD score every 6 months
2) AFP & US every 6 months
3) Endoscopy every 3 years for oeseophageal varices
Purpose of MELD score?
Gives an estimated 3-month mortality as a percentage for patients with liver cirrhosis
What is seen on a liver biopsy in alpha-1 antitrypsin deficiency? (1)
Periodic acid-Schiff positive staining globules in hepatocytes
When would a patient with ascites be given prophylactic antibiotics against spontaneous bacterial peritonitis? (1)
When there is <15 g/litre of protein in the ascitic fluid
Why does low protein in ascitic fluid predispose to spontaneous bacterial peritonitis?
It is thought that the antibacterial activity of ascitic fluid is closely correlated with the protein concentration. Thus, patients with low protein levels are at higher risk for SBP.
What is the inheritance pattern of Wilson’s disease? (1)
What gene is affected? (1)
Autosomal recessive
Wilson disease protein gene on chromosome 13 (ATP7B copper-binding protein)
Which hepatitis B marker indicates active viral replication and high infectivity? (1)
E antigen (HBeAg)
What condition involves duodenal or pancreatic tumour secretes excessive quantities of gastrin, resulting in excessive acid production in the stomach? (1)
What genetic condition is associated with developing gastrin-secreting tumours? (1)
Zollinger Ellison syndrome
MEN type 1
What disease is associated with anti-smooth muscle antibodies (anti-SMA)? (1)
Type 1 autoimmune hepatitis
What is the initial screening test for suspected Wilson’s disease? (1)
What result suggests Wilson’s disease? (1)
Serum caeruloplasmin
Low
What is giardiasis?
Caused by the flagellate protozoan Giardia lamblia.
How is giardiasis spread?
Faeco-oral route
Symptoms of giardiasis?
- often asymptomatic
- lethargy, bloating, abdominal pain
- flatulence
- non-bloody diarrhoea
- chronic diarrhoea, malabsorption and lactose intolerance can occur
Management of giardiasis?
Metronidazole
1st line investigation in giardiasis?
Stool microscopy
At what INR is it only recommended to carry out a liver biopsy?
INR <1.5
What type of laxative is macrogol?
Osmotic laxative
What type of laxative is docusate sodium?
Both stimulant and softening mechanisms of action
What is the most useful test for confirming the likely diagnosis of Primary Biliary Cholangitis?
AMA levels
What is usually the 1st line medication for gastroparesis?
Metoclopramide
What is the gold standard treatment for chronic hepatitis C?
Direct-acting antiviral (DAA) therapy e.g. sofosbuvir, ledipasvir and velpatasvir
What organism is associated with gastroenteritis caused by consumption of unpasteurised milk, unrefrigerated meat and dairy products in non-immunocompromised people?
Staph. aureus (staphylococcal enteritis)
